,2023 NCLEX RN Uworld Comprehensive
Study Guide 100 Pages PDF Download
Bonus 2,600 + Nclex Practice Questions
+ Rationals
what medications interact with grapefruit? - calcium channel blockers: diltiazem,
nifedipine, verapamil, etc
statins
caffeine
SSRIs
be sure to practice math! -
stent placement using the femoral approach puts you at risk for retroperitoneal
hemorrhage -
what are early signs of bleeding into the retroperitoneal space? - hypotension, back
pain, flank ecchymosis (grey turner sign), hematoma formation, diminshed distal pulses
what is the grey-turner sign and what is it a sign of? - bruising of the flanks and
retroperitoneal hemorrhage and is a bluish color
what are some physical signs of peripheral arterial disease? - intermittent calf muscle
pain?, rest pain, hair loss, decreased peripheral pulses, cool, dry, shiny skin, thick brittle
nails, gangrene, ulcers (all of these are in the extremities)
transplanted hearts are expected to be - tachycardic like 90-110
what is the priority intervention for pain with sickle cell crisis and why? - administer IV
fluids to reduce blood viscosity and restore perfusion to areas affected by vasoocclusion
what is the purpose of continuous bladder irrigation? - it is perscribed after TURP to
prevent obstruction of urine outflow by removing clotted blood from the bladder
what is the nurses care of monitoring CBI? - monitor quality of drainage, titrate the
inflow rate, and manurally irrigating as needed
characteristics of a basilar skull fracture - periorbital hematomas (raccoon eyes), csf
fluid rhinorrhea, and battle sign (behind the ear bruising)
,immediate client care for basilar skull fracture - cervical spime immobilization, close
neurologic monitoring, and support of ABCs
vomiting with intake may mean - viral or bacterial infection
tympanosomty tubes are placed for - recurrent otis medias
nurse actions during a seizure - assist them to lie down is standing/sitting, put them on
side for patent airway, loosen tight clothing, give oxygen as needed, remove objects
from immediate area, document time and duration of seizure (for tests are done later to
see which type of seizure and maybe what exacerates it)
never put anything in mouth or restrain them since musclec ontractions can occur
during a seizure
what are some early symptoms of ICP? - altered LOC, headache, abnormal reathing,
rise in bp, slow pulse, vomiting
client who has a TIA is often placed on - prophylactic antithrombotic treatment like
aspirin or clopidogrel
glascow coma scale ranges from - 3-15; 3 being worst 15 being best condition (8 or
below in a coma)
what are the 3 components? - eye opening
motor response
verbal response
what is a primary component in TPN? - glucose, so the nurse should be monitoring
blood glucose and be assessing for signs of hyperglycemia
when a client is on TPN, the nurse must assess for hyperglycemia why? - bc a primary
component is glucose. therefore the nurse must be assessing to see if the client is
getting too much glucose (hoerglycemia). and with a large urinary output like 4800, this
could indicate symptoms of hyperglycemia
signs og hyperglycemia - polydipsia, polyuria, restless, confused, bg over 200, fatigue,
kussmaul resp
what is the goal for mass casualty events? - do the greatest good for the greatest
number of people
keep in mind that disaster triage ranks the likelihood of survival with treatment, not
necessarily the severity of the injury -
what are the 4 categories for triaging? - immediate (red tag)- life threatening injuries
with good prognosis once treated
,delayed (yellow)- injuries requiring treatment within hours
minimal (green tag)- injuries requiring treatment within a few days
expectant (black tag)- extensive injuries, poor prognosis regardless of treatment
rule of nines - head: 4.5 front 4.5 back
torso: 18 front 18 back
each arm: 4.5 front 4.5 back (each arm is 9 total)
each leg: 9 front 8 back (each is 18 total)
genitals: 1
extrapyramidal side effects - ACUTE DYSTONIC REACTION: sudden onset sustained
muscle contractions
AKATHISIA: restlessness with inability to sit still
drug induce PARKINSONISM: tremor, rigidity, bradykinies, masked like faces
AKINISIA: loss of involuntary movement
TARDIVE DYSKININIA
NEUROLEPTIC MALIGNANT SYNDROME
dont give morphine if RR under 12 bc it can cause - respiratory depression
airborne precautions - tuberculosis, varicella, and rubeola (measles)
wear N95 respirator (and other as needed like for splashes)
ALSO (neg pressure room and HEPA)
clients suspected are to wear a surgical mask after triage
UAP soft wrist restraints can: - do ROM exercises
reapply wrist restraints
report changes in skin to nurse
turn/reposition client in bed
a client with major depression and severe weight loss needs what type of diet? - high
in calories and protein, also foods that are easy to chew and dont require a lot of energy
bc they may have a low energy level
examples: while milk/dairy, granola muffins, pottoes, meat fish eggs, pasta
also small frequent meals
memorize MAOIs and remember - they cant eat foods high in tyramine like aged
cheese, yogurt, fermented foods, beer, red wine, cocolate, avocados
do not give lasix to a pneumonia patient with fine crackles bc they dont result from heart
failure or edema -
you can give pneumonia patient exportants, antibiotics, mucolytics, antipyretics,
analgesics, and antinflammatories
examples are - Mucinex, Ibuprofin,
,decerebrate posturing (toes point down and amrs/legs straight out) is a sign of - severe
brain damage
near drowning hypothermia - warm iv fluids, blankets, and air
also will find weak and thready pulse
a client is not dead until warm and dead!!! - nc sometimes a pt is so cold that a pulse
cannot be felt
intussusception
causes intestinal obstruction - ileum telescopes into cecum, pain obstruction, edema,
compression of BVs, bowel ischemia, rectal bleeing (CURRANT JELLY stools)
signs of intussusceotion - inital periodic pain with legs drawn up to abdomen, pain is
severe and progressive though, inconsolable crying, blood/mucousy stools "current
jelly"
how is it treated? - an air enema
guaifenesin (Mucinex) - expecorant med that inc resp fluids and thins secretions to
facilitate expectoration
erythropoeitin Epogen - stimulates bone marrow to make RBCs and combats the
effects of chemo and used for kidney disease
when is hemoccult done? - when hidden (occult) blood is suspected due to dark and
tarry stool
treat intussusception with - AIR ENEMA
tetraology of fallot - exacerbation can happen when infant or child cries, becomes
upset, or is feeding
you immediately place them in KNEE CHEST position
hemolytic uremic syndrome - life threatening complication of e. coli diarhea
what are the signs? - anemia (pallor), low platelets (petechiae and purpura, and acute
kidney injury (low UO)
cognitive behavioral therapy (CBT) 5 basic components - education about pts disorder
self observing and monitoring
relaxation techniques
cognitive restructuring
behavioral strategies
, speicen collection from a foley is considered sterile and should not be delegated to uap
-
a clients first and last name is not PHI privileged health info - it is not a violation to cal
them by their first and last names or have info heard inadvertently
what happens if a client does not full undersnad infromed consent?q - the nurse must
contact the doctor. the nurse is not responsible for verifiying that the client understands
how to stop epistaxis - tilt the head forward and apply direct continuous pressure on
the alaes (sides) for about 5-20 mins
can also hold a cold washcloth to the bridge of nose for vasoconstriction
keep child calm and quiet
IV iodinated contrast used for ct scan can cause - kidney injury
metformin is discontinued on the day of IV iodine contrast exposure -
Amlodipine - calcium channel blocker used to treat hypertension
Gabapentin (Neurontin) - used for neuropathic pain
Phenytoin (Dilantin) - antiseizure
Glipizide - oral sulfonylurea controls blood sugar
Levofloxacin (Levaquin) - antibiotic
testicular self examination - perform monthly and on same day
perform while taking hot shower bc temps will relax scrotal tissue and make testis hang
lower in scrotum
use both hands to feel each testis separately
palpate gently using thumb and first 2 fingers
normal calcium level - 8.6-10.2
review heart rhythms -
lactated ringers is often used for burns -
addisons disease= hyperpigmentation of the skin -
what is one of the earliest signs of ICP? - change in respsonsiveness
